Published in The Lancet, the paper explains that the term ‘Fangcang,’ is borrowed from military field hospitals, and refers to a novel concept: “large, temporary hospitals built by converting public venues, such as stadiums and exhibition centres, into healthcare facilities to isolate patients with mild to moderate symptoms of an infectious disease from their families and communities, while providing medical care, disease monitoring, food, shelter, and social activities”.

Co-authored by Simiao Chen, from the Heidelberg Institute of Global Health in Germany, and Zongjiu Zhang, from the National Health Commission of the People’s Republic of China, the paper explains that as the outbreak in the city of Wuhan reached its peak, the city opened three Fangcang shelter hospitals on 5 February, by converting exhibition centres and stadiums. Over the following weeks, Wuhan opened an additional 13 Fangcang shelter hospitals. 

The hospitals building work consisted of installation of beds, sheltered space, and the three zones and two passages (san qu liang tong dao) common to hospital isolation wards. The three zones comprised a contaminated zone occupied by patients, a semi-clean zone where workers don and doff their protective suits, and a clean zone where supplies are received. Of the two passages, one is used for patients and the other for health workers. 

As the epidemic in Wuhan subsided and bed occupancy moved towards zero, operation of the Fangcang shelter hospitals was suspended. The first hospital closed on 1 March, and within ten days, all Fangcang shelter hospitals had been shut.

Key characteristics

The authors go on to describe three main characteristics of the hospitals: rapid construction; massive scale; and low cost.

Their rapid construction was made possible because they were based inside existing physical infrastructure. The conversion process was completed in 29 hours for the first three Fangcang shelter hospitals in Wuhan, providing 4000 beds. Some interior redesign of spaces was necessary, with the process also involving the purchase and installation of beds, medical devices, and supplies to support care, monitoring and sheltered living. 

The massive scale of the infrastructure involved ensured a significant increase in healthcare capacity. The 16 Fangcang shelter hospitals that China built contained 13,000 hospitals beds. By the time they were all closed, the hospitals had provided care for about 12,000 patients. 

And the third major characteristic is the low cost of building and running Fangcang shelter hospitals, as the conversion process avoids costly construction of new physical infrastructure. The authors also note that once the epidemic has subsided, the structures can be returned to their original purposes, avoiding long-term, inefficient use of space. Operational costs are low because of the low health worker-to-patient ratio; this is down to two reasons: first, all patients share the same primary admission diagnosis, reducing complexity of care; and second, all patients have only a mild to moderate form of the disease. 

“The Fangcang shelter hospitals improved the distribution of patients with COVID-19 according to the severity of their symptoms, increasing the overall efficiency of care,” states the paper.

Primary functions

Following description of these three key characteristics, the paper provides analysis of the hospitals’ five main functions: isolation; triage; basic medical care; frequent monitoring and rapid referral; and essentials living and social engagement.

Before the construction of the hospitals, thousands of patients with mild to moderate COVID-19 in Wuhan had to be sent home for isolation. And because these patients are generally more active than the severely ill, they are typically more active and increase the chance of transmission within the family and close community. The Fangcang shelter hospitals isolated COVID-19 patients more effectively from their communities than home isolation, the authors conclude. 

By inserting an additional level of care into the Chinese health system, the Fangcang hospitals served a strategic triage function by allowing the severely ill to be treated in traditional hospitals and separating them from those with more mild and moderate symptoms. 

As a third essential function, the shelter hospitals provided basic medical care, including antiviral, antipyretic and antibiotic medication; oxygen supplementation and intravenous fluids; and mental health counselling. Within a few days of the first Fangcang hospitals opening, health workers in Wuhan had access to electronic information systems connected with higher-level hospitals, for record keeping, data transfer, and monitoring of quality of care and outcomes.

The shelter hospitals were integrated into the overall health systems through simple referral and transfer pathways. Health workers at the facilities monitored the progression of disease in patients multiple times a day, and carried out specialised monitoring, if required, using imaging and laboratory services, which were available in mobile health units outside the hospitals. If patients met certain clinical criteria, they were quickly transferred to designated higher-level hospitals.

“Overall, Fangcang shelter hospitals are likely to have substantially reduced the time from the onset of severe symptoms to admission to a higher-level hospital, compared to the alternative of home isolation,” say the authors.

The fifth essential function provided by the hospitals was essential living and social engagement. 

The authors explain: “China conceived the Fangcang shelter hospitals as a community of patients, in which patients are isolated from the COVID-19-negative population but support each other and engage in social activities. Health workers provided emotional support, in addition to medical care; community activities included eating together, watching television, dancing, reading, and celebrating birthdays.”

Further considerations

Several other considerations for the running of Fangcang hospitals are explored in the paper. They include: 

• human resources – for example, mobilising health workers from across the country to staff the shelter hospitals, and training them accordingly; 
• communication and public engagement – to ensure the public is informed about the facilities and support their use; 
• governance – co-ordinating the delivery and operation of such facilities through necessary leadership bodies and organisations, with clear lines of responsibility; 
• prevention of nosocomial infection – including measures such as all patients being required to test positive for COVID-19 and negative for influenza before admission, and patients having to wear one to two protective masks each day, in order to lower the risk of transmission and acquisition of infectious respiratory diseases; and
• privacy – through, for example, contained partitions that separated bed units into spaces resembling hospital rooms and wards.

The authors also highlight several differences between Fangcang hospitals and makeshift and emergency field hospitals used during previous epidemics in other countries. One of the striking differences described by the paper is that the Fangcang hospitals also served as social spaces, providing essential living, emotional support and social engagement for the large numbers of patients who lived in isolation from their families and communities.

“During the COVID-19 outbreak in Wuhan, China, Fangcang shelter hospitals isolated thousands of patients, provided high-quality medical treatment and care, and fulfilled an important triage function,” conclude the authors. “Early descriptive evidence suggests that the Fangcang shelter hospitals were a major reason for the successful COVID-19 control in China. The number of confirmed cases in Wuhan steadily declined from 18 February 2020, 12 days after the first Fangcang shelter hospitals started admitting patients.”

They suggest that future research should establish the causal impact of Fangcang shelter hospitals on COVID-19 incidence and population health outcomes, adding: “By embracing Fangcang shelter hospitals, many countries and communities worldwide could boost their response to the current COVID-19 pandemic as well as future epidemics and disasters.”